Surrendered Bird History Form Owners Name * Address * City * State * ZipCode * Phone Number * EMail Address * Birds Name * Band Number Gender * Male Female Unknown Species Age Date of Birth/Hatch Reason for Surrender * Acquired From * Breeder Pet Store Rescue/Adoption Friend/Family Other Acquired From Name Acquired On Date Acquired From Address Acquired From City/State/Zip Has this bird been to a Vet recently? * Yes No Has the bird been seen by any other Vetrinarian? Yes No Are there any other birds in living in the same home? * Yes No Has this bird been exposed to bird(s) other then those listed previously within the last 180 days? * Yes No Are the birds wings clipped? Yes No Has this bird been routinely exposed to second-hand tobacco smoke or any other potentially hazardous substances in your home that might contribute to health problems later in the bird’s life? * Yes No Does this bird have a microchip implanted * Yes No Has this bird been DNA or surgically sexed * Yes No Please provide a brief health and medical history including any injuries, surgeries, or medication regimen that occurred while this bird was in your care. Have you experienced any behavioral problems with this bird? * Yes No Please describe this bird’s daily diet including specific brands, types, amounts, how prepared, and approximate time(s) given. Which items does the bird receive on a daily or regular basis? * Pellets Fruits Vegetables Nuts Seeds Treats Vitamins/Supplements People Food Please describe additional food items. Whats is the birds favorite foods? NOTE: The process of finding a new home can be made considerably less stressful for this bird if the things it is familiar and comfortable with, such as it’s cage, food/water bowls and toys, etc. accompany it.Do you plan to provide any of the following items along with the bird? Cage * Yes No T-Stand * Yes No Play Stand * Yes No Travel cage * Yes No Toys/Other items Where is the birds cage located in your home? Is there a window near the cage? * Yes No How many hours per day does the bird spend out of the cage? 0 hours 1 to 4 hours 5 to 12 hours 13 to 20 hours 21 hours or more How many hours per day is the bird normally left alone? (excluding sleep time) 0 hours 1 to 4 hours 5 to 8 hours 9 to 12 hours More than 12 hours When is this bird kept in the cage? What time of day is bedtime for the bird? What time of day does the bird wake up? Do you cover the bird at night? * Yes No Does the bird step up on command? * Yes No Is the bird 'Stick Trained'? * Yes No Has the bird every been toweled? * Yes No Does the bird have a phobia to sticks/towels/gloves? * Yes No Describe the birds favorite toys. Do you bathe the bird or does it bathe itself. * We Bathe Bathes itself How often and by what method? Are you the primary caregiver? * Yes No Are you the birds favorite person? * Yes No Has the bird shown a gender preference towards humans? * No Preference Prefers Men Prefers Women Prefers Children When left alone, this bird is normally * locked in the cage in the cage, doors open out of its cage Is a TV or radio left on when the bird is left alone? * Yes No Are the lights left on when the bird is left alone? * Yes No Does the bird talk? * Yes No Any offensive words? * Yes No Is there anything else that you feel we will need to know about this bird? What are your current plans as to how and when you will transport the bird for delivery?